lecture 9 common factors

What Works in Psychotherapy: Common

Factors

Introduction to Counseling

Kevin Standish

Learning Outcomes Describe some of the common

factors within different approaches to counselling

Describe the models and methods

Evaluate the relevance of the common factors as a unifying force within counselling

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Counselling training Helps organize, develop, and

skillfully use abilities we already have:

Empathy Communication Support Understanding Respect Trust

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Psychotherapy Research

Thousands of research studies of psychotherapy

Increase understanding of what works

Increase confusion about what works due to confl icting results

Meta-analytic research studies: studies of studies

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Quiz

Question 1:

Does psychotherapy work?

YES

40-70% of cl ients who receive psychotherapy show substantial benefit

At the end of therapy the average treated person is better off than the average untreated person.

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Conclusions from Meta-analytic Studies

Common Factors associated with Psychotherapy Outcome

“Extra-therapeutic” Factors (87%) Therapeutic Factors (13%)

Therapeutic Alliance (8%) Therapeutic Allegiance (4%) Therapy model or technique (1%)

Wampold, B.E. 2001. The Great Psychotherapy Debate: Models, Methods, and “Findings. Erlbaum.

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Conclusions from Meta-analytic Studies

Common Factors associated with Psychotherapy Outcome

“Extra-therapeutic” Factors (40%) Therapeutic Alliance (30%) Therapy Model or Technique (15%) Placebo Effect (15%)

Hubble, Duncan, Miller 1999. The Heart and Soul of Change: What Works in Therapy. APA

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Psychotherapy Models or Techniques

Account for a small amount of the variance in psychotherapy outcomes

Virtually all psychotherapy models and techniques are effective with some people, some of the time

Differences in outcome between models is consistently small or negligible

Outcome differences between therapists using the same model have been found to be 2-3 times greater than the differences between models

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Therapeutic Relationship and Alliance

Therapeutic Relationship

Trust Warmth Empathy Understanding Acceptance Genuineness Kindness

Therapeutic All iance

Client’s emotional relationship to the therapist

Client’ capacity to work in therapy

Therapist’s empathic understanding & involvement

Client-therapist agreement on therapy tasks and goals

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The most important therapeutic factors in a positive

psychotherapy outcome

A positive therapeutic relationship is considered crucial for a successful outcome in any type of psychotherapy

A strong therapeutic alliance is considered a necessary condition for therapeutic change to occur

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Dynamic not static: relationship and alliance change over time

More predictive of psychotherapy outcome than diagnosis

More predictive of psychotherapy outcome than model or technique

Predictive of client dropout

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The conclusion for therapists:

No matter what therapeutic No matter what therapeutic technique or model is used, it is technique or model is used, it is

not likely to be effective if there is not likely to be effective if there is not a strong client-therapist not a strong client-therapist

relationshiprelationship..

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Therapeutic Relationship Alliance and Therapy Model TechniqueThe therapeutic model or

technique used by a therapist is primarily effective if it matches the client’s “theory of change”:The client’s

View of the problemView of the change processGoals and expectationsDesired pace for treatment

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Therapeutic Relationship/Alliance and Therapy Model/Technique

The more therapy models and techniques a therapist can understand and use, the more options the therapist has for helping a wider range of clients.

An effective therapist should be able to use a variety of therapeutic models and techniques instead of assuming that each client will respond equally well to a particular model or technique.

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Therapeutic Relationship/Alliance and Therapy Model/Technique

A psychotherapist should use a

psychotherapy model or

technique to fit the client, rather than trying to make the

client f i t a particular model or

technique.

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3 Styles of Listening

1. Passive Listening – less effectiveListening to another personBeing interested in what that person

has to sayTrying to understand what that

person has to sayNOT communicating to that person

that we are interested and understand

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2. Competitive or Combative Listening –

Least effective Not really listening Thinking about what we want to say next More interested in expressing our point of

view than in understanding the other person

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3. Active Listening – Most Effective, powerful

Active Listening involves three main components:1. Listening to another person

2. Communicating to that person that we are interested in what they have to say

3. Communicating to that person that we understand what they have to say

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Building a strong therapeutic relationship

Active Listening Techniques Stop talking Let the client relax, take their time, explain things in their own way Physically show that you are interested

Face the client Open posture, e.g., don’t fold arms Maintain eye contact Reflect their body position (mirroring)

Remove distractions, stop whatever else you are doing Empathize: consider their point of view, “stand in their shoes” Don’t let you own emotions interfere or distract you Be cautious about disagreeing, criticizing, or arguing Ask questions to clarify, or encourage the client to say more or give an

example Don’t try to problem-solve (that may come later)

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Active Listening TechniquesParaphrasing

Summarize or repeat the facts of the situation

State your understanding of the thoughts, beliefs, feelings and emotions you heard

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Active Listening Techniques Paraphrasing example:

Client: “It seems like I cry all day. I don’t want to talk to anyone, even my friends. I don’t want to do anything, all I want to do is stay in my bed and sleep.”Therapist: “So you’re crying all the time, you don’t want to do anything or talk to anyone, and all you want to do is sleep. It sounds like you are feeling __________.”

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Active Listening Techniques If you are not sure you understand, express that to

the client: “I’m not sure I understand”, and ask for clarification: “could you tell me more?”, or “could you give me an example?”

OR If you are not sure you understand, try paraphrasing

anyway; if we are genuinely interested and trying to understand, clients will usually appreciate the effort and clarify for us: “No, I’m not really feeling sad. I just feel empty.”

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Active Listening Techniques If you disagree or disapprove of

what the client is sayingTry to be nonjudgmentalTry to be acceptingTry to be respectfulTry to understand their point of viewDon’t try to shame or embarrass the

other person

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Active Listening Techniques Don’t begin to problem-solve too soon

Often, if you continue to practice active listening, the client will develop their own solution to their problems

In psychotherapy it is almost always preferable to help clients develop their own solutions to problems Helps clients feel better about themselves Helps clients feel more confident in managing

future problems

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Active Listening Techniques It is okay to not have the solution to every

problem or a perfect understanding of the client.

Clients are the experts on themselves

Let the client teach you and guide you

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Extra-therapeutic FactorsAccount for major portion of improvement that occurs during

psychotherapy

How can a therapist use these factors in psychotherapy?

Listen for , invite, and use information about extra-therapeutic factors

What is different about better or worse days Ask about any between session improvement Help clients see any changes, and maintenance of changes, as

a consequence of their own efforts Even if clients attribute changes to luck, therapist skill,

medication, or some other factor, ask: How they adopted the changes in their lives What they did to use the changes to their own benefit What they will do in the future to maintain the changes

Ask about what happens in the client’s life that is helpful Encourage clients to explore and use resources in their life

and community

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The Client is Central

The capacity for self understanding, problem-solving, and growth, resides primarily in the client

The most effective therapists are ones who allow or help their clients develop their own understanding and solutions to problems

(It’s a relief to know that I don’t have to have all the answers)

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QuizQuestion 2

Who is better at identifying whether a cl ient is making progress in psychotherapy, the therapist or the client?

THE CLIENT

Research shows that therapists are remarkably bad at judging whether a client is making progress in psychotherapy.

The client’s experience of meaningful change , especially early in therapy (f irst 4-5 sessions) is one of the best predictors of a posit ive therapy outcome.

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QuizQuestion 3

Who is better at accurately rating the quali ty of the therapeutic relationship and therapeutic al l iance, the therapist or the client?

THE CLIENT

Research shows that the client’s rating is clearly superior to the therapist’s in predicting psychotherapy outcomes.

Research shows that the client’s rating is clearly superior to the therapist’s in predicting psychotherapy dropouts.

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Assessing and Tracking Psychotherapy Progress and the

Therapeutic Relationship/Alliance

Psychotherapy Effects: Progress in psychotherapy Continuously changing over the course of

treatment Faster or slower Better or worse

Psychotherapy Fit: The quality of the therapeutic relationship and therapeutic alliance Continuously changing over the course of

treatment

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Assessing and Tracking Psychotherapy Progress and the Therapeutic Relationship/Alliance

Psychotherapeutic processes, models, and techniques are best informed and directed by systematic and ongoing assessment of the “fit” and the “effect” of any given therapeutic relationship.

Therapeutic processes, models, and techniques are not well informed and directed by: Static concepts such as diagnosis Unreliable or inaccurate theories and impressions of the

therapist

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Routinely check with clients about whether they believe progress is being made:

Therapist: “How do you feel we’re doing?”OR

Therapist: “Let’s look at your goals. Do you feel like we are making progress?”

OR Therapist: “You look less overwhelmed. Are

you feeling that way?”

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Routinely check with clients about the relationship and allianceIs the therapist's approach helpful?Do they talk about what they want to

talk about?Do they feel heard, understood, and

respected?

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Use of rating scales (example)

Outcomes Rating Scale (ORS) Measures “Effect” Four rating scale items, 1-2 minutes to administer and score Administered, scored, and graphed at beginning of every

session Discuss and use improvement, decline, or no change

Session Rating Scale (SRS) Measures “Fit” Four rating scale items, 1-2 minutes to administer and score Administered, scored, and graphed at end of every session Discuss any low scores

Outcome Rating Scale (ORS)

Looking back over the last week, including today, help us understand how you have been feeling by rat ing how well you have been doing in the fol lowing areas of your l i fe, where marks to the left represent low levels and marks to the right

indicate high levels. I f you are f i l l ing out this form for another person , please f i l l out according to how you think he or she is doing.

Individually(Personal well-being)

I----------------------------------------------------------------------IInterpersonally

(Family, close relat ionships)I----------------------------------------------------------------------I

Socially (Work, school, fr iendships)

I----------------------------------------------------------------------IOveral l

(General sense of well-being)I----------------------------------------------------------------------I

Institute for the Study of Therapeutic Change_______________________________________

www.talkingcure.com© 2000, Scott D. Miller and Barry L. Duncan

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Session Rating Scale (SRS V.3.0)

Please rate today’s session by placing a mark on the line nearest to the descriptions that best fits your experience.

I did not feel heard, understood, and respected.

RelationshipI-------------------------------------------------------------I

I felt heard, understood, and respected.

We did not work on or talk about what I wanted to work on or talk about.

Goals and TopicsI-------------------------------------------------------------I

We worked on and talked about what I wanted to work on and talk about.

The therapist's approach is not a good fit for me.

Approach or MethodI------------------------------------------------------------I The therapist’s

approach is a good fit for me.

There was something missing in the session today.

OverallI------------------------------------------------------------I

Overall, today’s session was right for me.

Institute for the Study of Therapeutic Changewww.talkingcure.com

© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnsaon

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http://www.talkingcure.com/

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Chart # Client Name Therapist Date of Intake 1 2 3 4 5 6

1 220321RH Walton 1/12/2007 17.8 18.1 22 23.6 24.6 26.8

2 DAH Walton 1/23/2007 30.1 28.6 27.8

3 219632 Walton 2/4/2007 24.1 24.9 23.9 24.8

4 220012 FAL Walton 2/10/2007 5.4 7.9

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Conclusion Therapeutic Relationship and Alliance

o Of all therapeutic factors, it is the single best predictor of therapeutic outcome

Client is Centralo Therapist follows the client’s leado Client’s theory of change is crucialo Active listening

Ongoing, systematic assessment of client’s rating of “effect” and “fit”

o Client-directed, outcome informed treatment is the best guide to treatment decisions

You already have the basic abilities needed to be a good psychotherapist

o Relax and enjoy your work

lecture 9 common factors

Education